Monday, September 15, 2014

Will The Real Neuropsychiatrists Please Stand Up?

Recent dilemma - one of several people around the state who consult with me on tough cases called looking for a neuropsychiatrist. He had called earlier and I advised him what he might discuss with the patient's primary care physicians that might be relevant. I suggested a test that turned up positive and in and of itself could account for the subacute cognitive and behavioral changes being observed by many people who know the patient well. I got a call back today requesting referral to a neuropsychiatrist and responded that I don't really know of any. I consider myself to be a neuropsychiatrist but do not know of other psychiatrists who practice in the same way. There is one neuropsychiatrist who practices at the state hospital and is restricted to seeing those inpatients. There is one who sees primarily developmentally disabled persons with significant psychiatric comorbidity. There are several who practice strictly geriatric psychiatry. One of the purposes of this post is to see if there are any neuropsychiatrists in Minnesota. My current employment situation precludes me from seeing any neuropsychiatry referrals.

Neuropsychiatry is a frequently used term that is the subject of books and papers. Several prominent psychiatrists were identified as neuropsychiatrists. I went back to an anniversary celebration for the University of Wisconsin Department of Psychiatry and learned that early on it was a department of neuropsychiatry. It turns out that the Department of Neuropsychiatry was established in 1925 and in 1956 it was divided into separate departments of Psychiatry and Neurology. One of the key questions is whether neuropsychiatry is an historical term or whether it has applications today. The literature of the field would suggest that there is applicability with several texts using the term in their titles, but many don't even mention the word psychiatry. As an example, a partial stack from my library:

A Google Search shows hits for Neuropsychiatry and basically flat during a time when Neuroscience has taken off. Both of them are dwarfed by Psychoanalysis, but much of the psychoanalytical writing has nothing to do with psychiatry or medicine.

What does it mean to practice neuropsychiatry? Neuropsychiatrists practice in a number of settings. For years I ran a Geriatric Psychiatry and Memory Disorder Clinic. Inpatient psychiatry in both acute care and long term hospitals can also be practice settings for neuropsychiatrists. The critical factor in any setting is whether there are systems in place that allow for the comprehensive assessment and treatment of patients. By comprehensive assessment, I mean a physician who is interested and capable of finding out what is wrong with a person's brain. In today's managed care world a patient could present with seizures, acute mental status changes, delirium, and acute psychiatric symptoms and find that they are treated for an acute problem and discharged in a few days - often without seeing a neurologist or a psychiatrist. There may be no good explanations for what happened. The discharge plan may be that the patient is supposed to follow up in an outpatient setting to get those answers. That certainly is possible, but a significant number of people fall through the cracks. There are also a significant number of people who never get an answer and a significant number who should never had been discharged in the first place.

Who are the people who might benefit from neuropsychiatric assessment? Anyone with a complex behavioral disorder that has resulted from a neurological illness or injury. That can include people with a previous severe psychiatric disability who have acquired the neurological illness. It can also include people with congenital neurological illnesses or injuries. One of the key questions early on in some of these processes is whether they are potentially reversible and what can be done in the interim. Some of the best examples I can think of involve neuropsychiatrists who have remained available to these patients over time to provide ongoing consultation and treatment recommendations. In some cases they have assumed care in order to prevent the patient from receiving unnecessary care form other treatment providers. Aggression is a problem of interest in many people with neurological illness because it often leads to destabilization of housing options and results in a person being placed in very suboptimal housing. Treatment can often reverse that trend or result in a trained and informed staff that can design non-medical interventions to reduce aggression.

What is a reasonable definition? According to the American Neuropsychiatric Associationneuropsychiatry is "the integrated study of psychiatric and neurologic disorders". Their definition goes on to point out that specific training is not necessary, that there is a significant overlap with behavioral neurology and that neuropsychiatry can be practiced if one seeks "understanding of the neurological bases of psychiatric disorders, the psychiatric manifestations of neurological disorders, and/or the evaluation and care of persons with neurologically based behavioral disturbances." That is both a reasonable definition and a central problem. In clinical psychiatry for example, if a patient with bipolar disorder has a significant stroke what happens to their overall plan of care from a psychiatric perspective? In many if not most cases, the treatment for bipolar disorder is disrupted leading to a prolonged period of disability and destabilization. Neuropsychiatrists and behavioral neurologists practice at the margins of clinical practice. That is not predicated on the importance of the area, but the business aspects of medicine today. If psychiatry and neurology departments are established around a specific encounter and code, frequent outliers are not easily tolerated. Patients with either neuropsychiatric problems or problems in behavioral neurology can quickly become outliers due to the need to order and review larger volumes of tests, collect greater amounts of collateral information, and analyze separate problems. In any managed clinic, the average visit is typically focused on one problem. Neuropsychiatric patients often have associated communication, movement, cognitive and gross neurological problems. Some of these problems may need to be addressed on an acute or semi-acute basis.

Where are they in the state? Neuropsychiatrists are probably located in areas outside of typical clinics. By typical clinics I mean those that are outside of the HMO and managed care sphere. They can be identified as clinics that are managed by physicians rather than MBAs. The three largest that come to mind are the Mayo Clinic, the Cleveland Clinic, and the Marshfield Clinic. Apart from those clinics there are many free standing neurology and fewer free standing neuropsychiatric clinics. Speciality designations in geriatric psychiatry or neurology, dementias, developmental disorders, and other conditions that overlap psychiatry and neurology are good signs. There will also be psychiatrists in institutional and correctional settings with a lot of experience in treating difficult to treat neuropsychiatric problems. There may be a way to commoditize this knowledge and get it out to a broader audience. Since starting this blog I have pointed out the innovative pan in place thought the University of Wisconsin and the Wisconsin Alzheimer's Institute (WAI) network of clinics. They have impressive coverage throughout the state and provide a model for how at least one aspect of neuropsychiatry can be made widely available through collaboration with an academic program.

What should the profession be doing about it? The American Psychiatric Association (APA) and just about every other medical professional organization has been captive to "cost effective" rhetoric. IN psychiatry that comes down to access to 20 minutes of "medication management" versus comprehensive assessment of a physician who knows the neurology and medicine and how it affects the brain. The new hype about collaborative care takes the psychiatrist out of the loop entirely. The WAI protocol specifies the time and resource commitment necessary to run a clinic that does neuropsychiatric assessments. I have first hand experience with the cost effective argument because my clinic was shut down for that reason. We adhered to the WAI protocol.

What the APA and other medical professional organizations seems to not get is that if you teach people competencies in training, it is basically a futile exercise unless they can translate that into a practice setting. The WAI protocol provides evidence of the time and resource commitment necessary to support neuropsychiatrists. It is time to take a stand and point out that a psychiatric assessment, especially if it has a neuropsychiatric component takes more than a 5 minute checklist and treatment based on a score. A closely related concept is that total time spent does not necessarily equate with the correct or a useful diagnosis. I have assessed and treated people who have had 4 hours of neuropsychological testing and that did not result in a correct diagnosis.

If those changes occurred, I might be able to advise people who ask that there are more than two neuropsychiatrists in the state.